Tinnitus, Hyperacusis, and Misophonia Toolbox

Jill B. Meltzer, Au.D.1 and Melanie Herzfeld, Au.D.2

ABSTRACT

The management of tinnitus, hyperacusis, and misophonia can be a challenge to the audiologist, physician, and psychologist, as well as the patient and their family. Assisting the patient in identifying cognitive distortions or misperceptions can aid in the transition from one who suffers from these conditions to one who is able to manage them. Although there is no cure, it is inappropriate to tell patients that nothing can be done. The audiologist can help the patient learn techniques to lower the emotional impact of tinnitus. For those with an interest in tinnitus and sound sensitivity management, many tools are available. Most importantly, knowing when to refer is paramount. Compiling a referral list of medical and allied health providers, as well as audiologists who specialize in tinnitus, hyperacusis, and misophonia management, is in the best interest of the patient. Being familiar with the ever increasing list of available products and devices is necessary to build the tinnitus toolbox. This article will review current treatments, trends, and tools that may assist in patient education and tinnitus habituation. Some attention also will be paid to other sound sensitivities such as hyperacusis and misophonia.

KEYWORDS: Tinnitus, hyperacusis, misophonia

Learning Outcomes: As a result of this activity, the participant will be able to (1) compare multiple tinnitus treatments that are currently available and (2) list several devices available for tinnitus management.

A germinal article by Heller and Bergman tus, 94% of the normal-hearing subjects re- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. investigated the presence of tinnitus in normal- ported tinnitus when the environment was hearing subjects.1 Although 73% of their quiet enough. The consensus of these authors subjects with hearing loss reported some tinni- was that tinnitus is likely to be subaudible but

1North Shore Audio-Vestibular Lab, Highland Park, Illi- Tinnitus, Hyperacusis, and Misophonia; Guest Editors, nois; 2Hearing and Tinnitus Center, Woodbury, New York. Diane F. Duddy, Au.D. and Laura A. Flowers, Au.D. Address for correspondence: Melanie Herzfeld, Au.D., Semin Hear 2014;35:121–130. Copyright # 2014 by Hearing and Tinnitus Center, 113 Crossways Park Dr. Thieme Medical Publishers, Inc., 333 Seventh Avenue, #101, Woodbury, NY 11797 New York, NY 10001, USA. Tel: +1(212) 584-4662. (e-mail: [email protected]). DOI: http://dx.doi.org/10.1055/s-0034-1372528. ISSN 0734-0451. 121 122 SEMINARS IN HEARING/VOLUME 35, NUMBER 2 2014

present in almost everyone and therefore could uation is best defined as the lack of a response to not be eliminated. Making tinnitus subaudible a stimulation; to be unaware of tinnitus unless would therefore be the goal of tinnitus man- one decides to look for it. For some patients, the agement.1 From this perspective, audiologists loudness of the masker became a secondary use the management techniques discussed in disturbance and thus maskers fell out of favor this article to aim for the subaudible status for some years. Recent masking paradigms have Heller and Bergman referenced. trended more toward partial masking. In TRT, “A strong case can be made that audiolo- for example, Jastreboff and Hazell recommend gists are in the best position of all healthcare using the mixing point, or the point where one professionals to serve as the primary treatment hears the tinnitus change because of the pres- provider for patients with tinnitus.”2 First, ence of a mingling sound.10 Tyler et al suggest audiologists fit hearing aids that are often an that the use of maskers set to the mixing point effective first step in tinnitus management. may not be the only method to achieve habitu- When hearing loss is present and tinnitus is ation.11 Their study showed no significant reported, hearing aids may serve a double difference between three groups—one group benefit of improved communication and tinni- receiving counseling and utilizing maskers set tus reduction.3 Second, audiologists routinely to the mixing point, one group using full counsel patients about hearing loss and listen- masking along with counseling, and one group ing strategies to improve communication skills. receiving counseling alone. Although the num- Counseling plays a significant role in most ber of subjects in this study was small, it is successful tinnitus management programs.4,5 noteworthy that the groups with the greatest Directive counseling is a key aspect of Tinnitus degree of positive change on inventories were Retraining Therapy (TRT); other tinnitus the groups who had counseling and masking set management strategies advocate collaborative to the mixing point used in tandem, even if the or patient-centered counseling.6 numbers were not reaching significance.11 How successful can audiological tinnitus Time will tell if full masking regains the confi- management be? In a study by Herzfeld and dence and recommendations of audiologists Kuk,7 as many as 90% of patients who had and tinnitus patients. hearing loss were able to significantly reduce Goodey states that we do not really manage their tinnitus reaction by using combination tinnitus, rather we manage the patient who has amplification and tinnitus devices. Other studies tinnitus.12 He has suggested that there are three have shown significant reductions in tinnitus categories of tinnitus treatment. The first cate- handicap or tinnitus reaction ranging from 60 to gory is aiding the input, or auditory side, to 85% with the use of counseling, TRT, Neuro- normalize sensory inputs for the patient. This monics Tinnitus Treatment (Neuromonics, includes correcting any auditory loss and again Inc., Westminster, CO), sound generators, points to the use of amplification to offer the and even hearing aids.8 The definition of success patient an enriched auditory environment. in most studies is a 20-point difference or 40% Think back to the original study of Heller reduction on a tinnitus inventory comparing and Bergman1; in a sound-treated environment pretreatment to posttreatment scores.8 where the noise floor was so low, the normal- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Sound generators or maskers are not new. hearing subjects heard their tinnitus. Once out As Hippocrates noted in 400 BC, the “greater of that special environment, they did not. sound drives out the less” in discussing why Similarly, if we surround the area of tinnitus buzzing seemed to be lessened in the presence with sound via amplification, a large number of of external sounds. In 1976, Jack Vernon may tinnitus patients will immediately hear less have been one of the first to advocate wearable tinnitus. This is not aiming toward habituation, masking devices to aid in tinnitus manage- only reducing the time tinnitus is heard. ment.9 Although allowing the noxious sound The second category Goodey discusses is of tinnitus to be masked using broadband white controlling the emotional factors.12 It cannot be noise, questions arose regarding whether habit- stressed enough that emotional factors are cited uation, the ultimate goal, was possible. Habit- in virtually every tinnitus management TINNITUS, HYPERACUSIS, AND MISOPHONIA TOOLBOX/MELTZER, HERZFELD 123 program, as it is the emotional response that dark room versus a candle in a lit room. drives the tinnitus into the disturbance area. Although the candle is equally bright in both Consider the auditory mechanism as a go/no go scenarios, we typically judge its impact as less in type of system. In most cases of tinnitus, there is a lit room. Thus, by surrounding the tinnitus an excess of energy transmitted. The subcortex sound with other sounds, it may be described as or cortex then has a choice to acknowledge the less loud or noticeable as in a quiet room. tinnitus or ignore it. Once it is acknowledged, As mentioned previously, audiological the next level of go/no go is whether or not the management of tinnitus should always include tinnitus is bothersome or just present. If both- some aspect of counseling. The counseling ersome, the limbic system and autonomic ner- commences as soon as the appointment begins. vous system become involved. Reduction of the At its core, counseling can be thought of as emotional impact of tinnitus and ultimately of education. Being an informed, but empathetic the tinnitus perception is the basis of most listener and reassuring the patient that others tinnitus management systems,13 whether one have experienced disturbing tinnitus and have considers directive counseling via TRT, in found relief provides hope. Counseling may which one learns information about tinnitus help the patient understand their tinnitus, and why one’s emotional response drives the enabling a reduction of fear and distress.17 tinnitus to the forefront,14 or traditional cogni- Negative counseling can have disastrous effects tive behavioral therapy (CBT),15 or even cog- on the person suffering from tinnitus. Numer- nitive behavioral integration (CBI) as ous times patients have gone to their physician promulgated by Sweetow.16 In all cases, the and/or audiologist with a primary complaint of goal is behavior management and change. tinnitus only to be told, “There’s nothing you Think of tinnitus and the brain as a Pavlovian can do about it, just live with it, it’s incurable,” model. If the brain looks at tinnitus as a and they leave more distressed. Stephen Na- negative event, then it will cause a reaction gler,18 Medical Director of General Hearing each time it is acknowledged. It is difficult to Instruments, says it well in his “Patient Per- extinguish this conditioned response if it has a spective.” In this document, he states that a negative connotation. Thus, the goal of the physician can take 5 minutes and either tell the counseling portion of tinnitus management will patient there is no cure or instead take the time revolve around changing behaviors and to say that although there is no cure, there are attitudes.15 professionals with an interest in tinnitus who The third category Goodey references is may be able to help them. Offering hope, the use of what he terms “direct approaches to reassurance, and empowerment to the patient the central nervous system.”12 Neuroplastic is a significant first step, fostering confidence in changes can be influenced by the use of med- becoming the manager of the tinnitus and not ications, dietary modifications, electrical stim- the victim of it. ulation, magnetic stimulation, and even surgical considerations. He suggests that even if these things can foster neuroplastic changes, they Cognitive Behavioral Therapy require influences of psychological and sensory CBT addresses some of the automatic negative This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. inputs.12 thoughts associated with tinnitus perception. Automatic thoughts can be neutral, negative, or positive. In CBT, the goal is not to change the TINNITUS AND SOUND actual perception of the tinnitus but instead to SENSITIVITY MANAGEMENT acknowledge and alter the maladaptive METHODS thoughts and reactions to the tinnitus.15 In The main goal of tinnitus management using his “Letter to a Tinnitus Sufferer,” Nagler sound therapy is to lower the strength of the referred to these as cognitive distortions and tinnitus signal. If we increase the level of counseled the tinnitus sufferer to practice and surrounding sound, we frequently make the pay attention to these distortions, as they are tinnitus appear lower.10 Picture a candle in a the basis of finding relief.19 CBT often uses an 124 SEMINARS IN HEARING/VOLUME 35, NUMBER 2 2014

“A-B-C” model: A is the situation or event that and sensations. In Western culture, Jon Kabat- leads to the thoughts and beliefs about the Zinn is credited with bringing mindfulness to event, or B. The thoughts lead to C, the today’s modern medicine. He founded the emotional consequences. Henry and Wilson mindfulness-based stressed reduction program devote an entire chapter in their book to the at the University of Massachusetts Medical connection between thoughts and emotions.20 Center. Mindfulness has found its way into CBT teaches the patient to identify, evaluate, tinnitus treatment. Psychologist Jennifer Gans and respond to their dysfunctional thoughts has used it in a pilot program entitled “Mind- and beliefs, thereby educating in a collaborative fulness Based Tinnitus Stress Reduction.”22 way, to change thinking, mood, and behavior.5 The actual perception of the tinnitus is second- ary to the severe negative reaction to the Tinnitus Retraining Therapy tinnitus. TRT, as described and implemented by Jastreb- Additionally, the patient who is constantly off and Hazell,10 is based on a neurophysiologi- monitoring their tinnitus will never find relief. cal model of tinnitus and has applications in For some, the continuing questioning of “How tinnitus, hyperacusis, and misophonia treat- long until I habituate” or “Must I still wear my ment. The therapy depends on brain neuro- devices?” indicates that the patient is still plasticity and the ability of the brain to actively monitoring and tinnitus will continue habituate to unimportant signals. TRT assumes to be a problem.21 The more a person “visits” or that tinnitus is a phantom perception and the “listens in” for their tinnitus, the more likely distress from tinnitus includes nonauditory they will find it. Equally counterproductive are brain networks such as the limbic and auto- the patients who spend every waking moment nomic nervous systems. Therefore, the auditory scouring the Internet searching for any and all system is secondary for clinically relevant tinni- sources related to tinnitus. It is important to tell tus. In TRT, the counseling aspect attempts to these patients that too much time spent inves- reclassify the tinnitus as a neutral stimuli in- tigating tinnitus is not helpful in tinnitus stead of a negative one. If the tinnitus is judged management. To address excessive patient to be neutral, the degree of tinnitus reaction is monitoring and investigation of tinnitus, dis- lessened and habituation is more likely.10 traction techniques are another essential part of According to Jastreboff and Hazell,10 hy- CBT. A person can be very aware of any peracusis results from increased gain in the number of sensations if they turn their attention auditory pathways and is determined by the to it. Feeling my feet in my shoes, my ring on sound characteristics; the character or meaning my finger, my watch on my arm are sensations of the sound is irrelevant. It is simply that the available to me, but these are not sensations that loudness of the sound is uncomfortably loud demand attention. Pointing these out to the (and therefore troublesome), as determined by patient can be helpful exercises in redirecting loudness discomfort levels. The limbic system is attention away from the tinnitus. The impor- not necessarily involved. Hyperacusis should in tance of being able to refocus, reimage, and actuality be considered before tinnitus manage- reimagine is vital. Finally, learning the guide- ment. It is impossible to effectively manage This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. lines of relaxation, deep breathing, and guided tinnitus if the sound level of the masker or imagery is a necessary component of this sound generator is too loud for the patient to therapy. tolerate.10 TRT addresses another sound sensitivity condition termed misophonia. Misophonia dif- Mindfulness-Based Stress Reduction fers from true hyperacusis in that the limbic and Mindfulness therapy is another counseling- autonomic nervous systems are integral com- based therapy that may be helpful for tinnitus ponents of the negative feedback loop. Its patients. With mindfulness-based stressed re- definition was first promulgated by Jastreboff duction, one pays attention to thoughts and and Hazell just over a decade ago.10 Another sensations without judgment of those thoughts term frequently associated with misophonia is TINNITUS, HYPERACUSIS, AND MISOPHONIA TOOLBOX/MELTZER, HERZFELD 125 selective sound sensitivity syndrome, intro- shown deep breathing exercises, progressive duced by Portland audiologist, Marsha John- relaxation, and guided imagery. The patient is son. Misophonia is a reaction to sounds, not instructed to find environmental sounds, such relative to loudness, but instead to the emo- as music or speech, that fall into the categories tional impact of specific sounds. In misophonia, of soothing, background, and interesting. By specific sounds, such as chewing, eating and rating these sounds on a success scale, the mouth sounds, breathing, tapping or clicking, patient can find sounds that help soothe, dis- or even repetitive visual triggers, elicit a severe tract, engage, or work as a background sound. negative emotional and physical reaction, which This Veterans Administration step-manage- is commonly anger and disgust. We often refer ment approach starts with a group encounter to these debilitating sounds as trigger sounds. to help the veteran learn how to fill out the Misophonia engages the limbic system in a sound-rating sheets to find sounds that are powerful, negative way and a conditioned reflex beneficial. The veteran returns a few weeks is established. Loudness discomfort levels are later for a discussion of how beneficial the often normal in the misophonic patient. Asso- sound files were for their tinnitus. For many, ciating the disliked sound with something these group sessions provide sufficient help in positive is the fastest way to reverse the condi- tinnitus management. Further help is given for tioned response.4 By giving the patient a chance those who need amplification, have additional to identify the disturbing sound as a pleasant counseling needs, and require individual ses- one, we can help the misophonic patient learn sions.6 The ATA supports local group meetings to reverse the reflex. For example, if the sound that allow tinnitus patients to meet one another, of a crunching potato chip (trigger sound) is to share stories, to share successes and failures, mixed with the sound of a campfire on a beach and to learn about tinnitus management op- (pleasant association), or if the sound of clip- tions and research. ping nails (trigger sound) is thought instead as the sound of horses clopping through the park or the sound of roses being clipped (pleasant Tinnitus Activities Treatment association), then the association can be made Tyler and colleagues at the University of Iowa less unpleasant. Think of it as a pain-manage- provide online tools as part of the Tinnitus ment technique. One does not need to experi- Activities Treatment program to assist the ence needles to learn how to cope with audiologist in tinnitus management.23 Through injections, but instead would benefit from the university’s Web site (see Appendix A), the learning how to focus away from the pain. tinnitus patient is offered downloadable ques- Those of us who have worked with misophonic tionnaires to identify specific areas of tinnitus patients have found this to be true. impact, surveys to describe their tinnitus expe- According to the TRT model, treatment rience, and directions to participate in tinnitus for hyperacusis and misophonia must be differ- and hyperacusis trials. The Web site also offers ent as the role of the limbic system and auto- counseling presentations covering thoughts and nomic nervous system are not the same. emotions, hearing and communication, sleep, concentration, and different sound therapies This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. available for tinnitus management. These pre- Progressive Tinnitus Management sentations are both helpful for the tinnitus The Veterans Administration reports a large patient as well as the audiologist working number of veterans with service-connected with the tinnitus patient.23 tinnitus. As a result, Henry et al produced and published the Progressive Tinnitus Man- agement (PTM) workbook with accompanying ASSESSMENT AND MANAGEMENT videos.6 PTM is available as a member benefit of the American Tinnitus Association (ATA) Building the Tinnitus Toolbox or through online booksellers. As part of the When evaluating the tinnitus population, the PTM approach, the patient with tinnitus is importance of assessing the impact of tinnitus 126 SEMINARS IN HEARING/VOLUME 35, NUMBER 2 2014

cannot be overstated. There is no direct corre- needs of the patient exceed our scope of lation between the psychoacoustic character- practice. istics of tinnitus (pitch, loudness, sound Tinnitus often disrupts concentration and quality, etc.) and the degree of reaction.10 sleep. Sleep disturbances are often cited as one Therefore, it is very important to consider of the comorbidities of tinnitus. According to the areas of greatest impact; including when Cronlein et al,28 45% of patients with new and how tinnitus interferes. There are inven- tinnitus report sleep disturbance. Some mourn tories/questionnaires that can assist the audi- the loss of a quiet night of sleep, others lament ologist in first assessing the level of tinnitus the inability to sleep without awakening in the disturbance or handicap and subsequently middle of the night. For many patients, ad- monitor treatment progress. The Tinnitus dressing the sleep-deprivation issue can be a Handicap Inventory is a 25-item question- good start to managing tinnitus. There are naire, whereby the patient answers yes, no, or products specifically designed for sleep man- sometimes to each item. The Tinnitus Handi- agement, such as sound pillows, pillow speak- cap Inventory is easily scored and can give a ers, Bedphones, and SleepPhones, which quick assessment of how the tinnitus impacts deliver sound at ear level throughout the night. daily activities.24 The Tinnitus Reaction Ques- In addition, the sound source may be emitted tionnaire is a 26-item inventory to assess from a cell phone through a noise app, tablet, or tinnitus distress levels, asking the patient to from a tabletop sound machine. Certain med- rate each item from 0 (not at all) to 4 (all the ications, such as benzodiazepines or other time).25 The Iowa Tinnitus Handicap Ques- sleep-inducing products, may be prescribed tionnaire was developed in 1990 by Kuk et al for sleep management. However, the sooner and has 27 questions.26 Answers to the items sleep problems are addressed and tinnitus man- range from 0 (strongly disagree), to 100 agement implemented, the less likely the pa- (strongly agree). The Tinnitus Functional In- tient is to seek drug therapy. TRT suggests dex assesses eight aspects of tinnitus: intrusive- avoidance of benzodiazepines, because they ness, concentration, sleep, sense of control, slow the progress toward habituation and alter cognitive, auditory, relaxation, and quality of perception.10 Ultimately, it is recommended life.27 These are but a few of the currently that patients seek physician advice regarding validated tools that may be used to measure and appropriate medications for sleep. monitor tinnitus outcomes. Somatosensory inputs can alter the level of What kind of management strategies can tinnitus, whether from temporomandibular be implemented for those with tinnitus and joint disorders, neck involvement, or myofascial other sound sensitivity disorders? The distress triggers. Thus, patients may complain of neck level (as indicated by the inventory and/or and/or back issues or jaw clenching and teeth tinnitus history) will dictate the aggressiveness grinding. Surprisingly, just knowing that this of the treatment. Many people experience tin- may be the source of the problem relieves some nitus in a form they would consider acceptable, of the patient’s anxiety. It is beneficial to build a whereas others consider their tinnitus to be referral list of physicians and dentists who completely unacceptable and are severely debil- specialize in these issues, as treatments for This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. itated. Some find the level of tinnitus distur- neck, back, or temporomandibular joint disor- bance to be minimal. For them, reassurance and ders may help alleviate tinnitus. For example, some minor sound therapy is often enough. patients may be told to change their pillow One can use ear-level devices or environmental array, or perhaps to sleep with a wedge to sounds to help reduce tinnitus awareness. For change the body alignment at night. Some others, the level of disturbance is higher and patients benefit from physical therapy or have these patients may need more counseling or a received injections in specific sites as a result of referral to a psychologist, social worker, or these referrals. Understanding the need for and psychiatrist. The value of referral lists cannot providing referrals for these specific issues may be overstated. Although we may be trained in improve the success of the tinnitus-manage- counseling, we also need to know when the ment program. TINNITUS, HYPERACUSIS, AND MISOPHONIA TOOLBOX/MELTZER, HERZFELD 127

Tinnitus Devices tinnitus toolbox. There should be a variety of There are specific treatments and devices that tinnitus management tools to demonstrate with have been designed, marketed, and approved a tinnitus patient. The various music type for tinnitus management that will be discussed, therapies should be represented, including such as Neuromonics Tinnitus Treatment, the PAXX, Serenade, and Neuromonics, with the SoundCure Serenade device, and the PAXX Oasis, Sanctuary, and soon to be Haven devices, tinnitus device. This is not an endorsement of a as well as various sound therapy options. particular management option; some may be Neuromonics’ premier programmable and more beneficial than others. Each option is a customized device, the Oasis, will soon be tool developed with the goal of tinnitus habit- programmable through NOAH via USB, and uation, relief, and management. As mentioned will offer a new progressive muscle relaxation previously, hearing aids, sound generators, or track (guided meditation) and three additional combination devices also may be very effective tracks. The original device had two Baroque options. Currently, many of the hearing aid tracks and two New Age tracks. Two of the manufacturers have combination amplification additional tracks will be the baroque style of and tinnitus devices, and the options are rapidly music and the third track will be nature sounds increasing. One can now choose from fractal or a new age track. The clinician will be able to music and relaxing tones, white noise, pink choose four of the seven (two Baroque and two noise, frequency-shaped noise, narrowband New Age tracks) for downloading into the noise, as well as streaming capabilities through device. The Haven, a new FDA-cleared second wireless accessories. Streamed auditory signals tier device from Neuromonics also will be may include music, environmental sounds, programmable through NOAH and will offer noises, and even books. Environmental sounds the phase 1 tracks (including adjustable white such as fish tanks, fan noise, waterfalls, televi- therapy noise), a data logging feature, and a sion, and radio may be used to effectively balance control for auditory asymmetries. It also manage tinnitus. will have the progressive muscle relaxation track Widex is one hearing aid manufacturer built into the device. The Neuromonics Sanc- with a U.S. Food and Drug Administration tuary is an entry-level, noncustomized device, (FDA)-cleared device for tinnitus management that plays four tracks of music, all with the called the Zen program. Under the tutelage of therapy noise embedded. The Sanctuary is Robert Sweetow, Zen therapy includes sup- designed for those whose hearing loss falls in porting materials for CBI, an approach imple- specific and symmetrical categories. menting cognitive behavioral awareness. In The SoundCure Serenade is a commercial- CBI, patients are divided into five categories ly available and FDA-approved tinnitus treat- based on inventory scores. These categories ment device with four therapy tracks. Two determine how the Zen is programmed.16 Sim- tracks are S-Tones, which are unique to Sound- ilarly, GN ReSound has published a reference Cure and are based on personalized pitch and guide and supporting materials for use with loudness matching procedures; the additional their combination devices, which includes edu- tracks offer narrowband and white noise. There cational information on tinnitus and tinnitus is an independent control for each ear for which This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. management. At the time of this writing, any auditory asymmetries can be compensated. Starkey, Phonak, Siemens, Unitron, General The device also is customized based on hearing Hearing Instruments, and Amplisound now thresholds and loudness discomfort levels.29 provide tinnitus and/or combination devices. The PAXX tinnitus device is made by the Each company has produced documents to Tinnitus Laboratory in collaboration with the assist the audiologist. The audiologist interest- Montreal Tinnitus Clinic. The customized ear- ed in tinnitus management will benefit from level device produces intermittent sounds in the searching out these documents and available region of hearing loss to promote tinnitus research supporting these tinnitus devices. habituation. The suggested paradigm of use is After creating a referral list, there are increasing length of passive listening from 10 to additional items that belong in the audiologist’s 30 minutes four to six times daily. 128 SEMINARS IN HEARING/VOLUME 35, NUMBER 2 2014

The audiologist’s tinnitus toolbox should oflavinoids. Note that the authors are not includeasampleofmanyofthedevices endorsing these products on evidence-based mentioned previously. It is impossible to criteria, only stating that they are available predict what sound a patient will prefer. and have worked for some. Information on Additionally, the tinnitus toolbox should the various herbal remedies also will find its include tools that may be beneficial for mi- way into your toolbox; whether or not these are sophonia and hyperacusis management. In helpful, patients will inquire about them. The cases of hyperacusis, a sound generator clinician must be prepared to discuss whether worn over a prolonged amount of time is gingko or dong quai root can be beneficial for helpful in allowing the patient to acclimatize tinnitus patients. What are the contraindica- to the offensive sounds. tions to these products? What are the side It is helpful to have some distraction tools effects? The information must be as accurate or tricks in the toolbox to reduce the concen- and current as possible, but presented in a tration and attention being given to the tinni- positive manner. tus. Even simple things such as stress balls have The toolbox should include hearing pro- found their way into our toolbox. Amass a tection. It would certainly behoove the tinnitus variety of programs to assist the tinnitus patient patient attending a loud event to protect his or in relaxation. Techniques such as guided im- her ears from further damage. At the same time, agery, progressive relaxation, and deep breath- it must be cautioned that the use, or more ing exercises can facilitate both stress and specifically, the overuse of ear protectors actu- anxiety reduction. Lists of Web sites that ally encourages hyperacusis and only should be might be helpful should be in the toolbox considered when the level of the sound is truly (see Appendix A). For example, the ATA damaging. Too often we hear that audiologists has a sound mixer on its Web site, which allows and physicians are recommending custom- the patient to select a combination of sounds made plugs for patients with sound sensitivity that can be mixed and exported to an electronic to be worn more or less continuously. That is file and replayed later. Search and compile a list not a situation whereby the patient improves; it of apps for sound therapy and relaxation that only serves to continue to add to the auditory are available for smartphones and tablets. Try deprivation and increases the sound them out with patients and at home, and fine- sensitivity.31 tune this list often. Often these apps are free and patients appreciate this simple, yet effective option. SUMMARY There is some evidence that notched music Tinnitus, hyperacusis, and misophonia are au- might be helpful for one with tonal tinnitus, if ditory disturbances. They are real, but they do played over the course of a year.30 Therefore, not have to be debilitating. The more the guiding the patient on creating their own patient feels hopeless, helpless, and out of notched music file, or simply providing them control, the worse the tinnitus, the hyperacusis, information, is recommended. One can find and misophonia become. Learning how to help online demonstrations to learn how to create the patient regain a feeling of control is very This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. and record notched versions of one’s favorite powerful for the patient. The more tools we music. For some patients, the do-it-yourself is have to offer our patients, the better they will be not possible, so the toolbox should include the at managing their tinnitus, their hyperacusis, things needed to offer the notched music to and their misophonia. patients as a customized tool. There are vitamins that might be helpful, especially in the case of new tinnitus, and REFERENCES information on these products should find their way into the toolbox. For example, Premier 1. Heller MF, Bergman M. Tinnitus aurium in Micronutrient Corporation has a vitamin for normally hearing persons. Ann Otol Rhinol Lar- hearing health, a product in addition to lip- yngol 1953;62(1):73–83 TINNITUS, HYPERACUSIS, AND MISOPHONIA TOOLBOX/MELTZER, HERZFELD 129

2. Henry J. Audiologic assessment. In: Snow J, ed. tinnitus management. In: Moller A, Langguth B, Tinnitus Theory and Management. Hamilton, DeRidder D, Kleinjung T, eds. Textbook of Tin- Ontario: BC Decker Inc.; 2004;220; nitus. New York, NY: Springer; 2011:535–555 3. Sheldrake J, Jastreboff M. Role of hearing aids in 18. Nagler S. Patient perspective. 2003. Available at: management of tinnitus. In: Snow J, ed. Tinnitus www.tinn.com. Accessed December 4, 2013 Theory and Management. Hamilton, Ontario: BC 19. Nagler S. Letter to a tinnitus sufferer. 2013. Decker Inc.; 2004:310–313 Available at: http://www.ata.org/nagler-letter-to- 4. Tyler R, Noble W, Preece J, Dunn C, Witt S. tinnitus-sufferer. ATA 3:1. Accessed January 8, Psychological treatments for tinnitus. In: Snow J, 2014 ed. Tinnitus Theory and Management. Hamilton, 20. Henry J, Wilson P. Tinnitus: A Self-Management Ontario: BC Decker Inc.; 2004:314–323 Guide for the Ringing in Your Ears. Boston, MA: 5. Henry J, Wilson P. Cognitive behavioral therapy Allyn & Bacon; 2002. Ch.4. 41–58 for tinnitus. In: The Psychological Management of 21. Tyler R. Tinnitus Treatment: Clinical Protocols. Chronic Tinnitus: A Cognitive Behavioral Ap- New York, NY: Thieme; 2006;181; proach. Needham Heights, MA: Allyn & Bacon; 22. Gans J. Mindfulness based tinnitus therapy is an 2001:63–94 approach with ancient roots. Hear J 2010;63:52–56 6. Henry J, Zaugg T, Myers P, et al. Progressive 23. Tyler R and The University of Iowa. Otolaryngolo- Tinnitus Management. San Diego, CA: Plural gy—Head and Neck Surgery: Tinnitus and Hyper- Publishing; 2010:8–11 acusis. 2006. Available at: http://www.medicine. 7. Herzfeld M, Kuk F. Clinician’s experience with uiowa.edu/oto/research/tinnitus/. Accessed Decem- using fractal music for tinnitus management. Hear ber 4, 2013 Rev 2011;18(11):50–55 24. Newman CW, Jacobson GP, Spitzer JB. Develop- 8. Davis PB, Wilde RA, Steed LG, Hanley PJ. ment of the tinnitus handicap inventory. Arch Treatment of tinnitus with a customized acoustic Otolaryngol Head Neck Surg 1996;122(2): neural stimulus: a controlled clinical study. Ear 143–148 Nose Throat J 2008;87(6):330–339 25. Wilson PH, Henry J, Bowen M, Haralambous G. 9. Johnson R. The masking of tinnitus. In: Vernon J, Tinnitus reaction questionnaire: psychometric ed. Tinnitus Treatment and Relief. Boston, MA: properties of a measure of distress associated with Allyn & Bacon; 1998:164–165 tinnitus. J Speech Hear Res 1991;34(1):197–201 10. Jastreboff P, Hazell J. Tinnitus Retraining Therapy; 26. Kuk FK, Tyler RS, Russell D, Jordan H. The Implementing the Neurophysiological Model. New psychometric properties of a tinnitus handicap York, NY: Cambridge Press; 2004. Ch.3. p. 17 questionnaire. Ear Hear 1990;11(6):434–445 11. Tyler RS, Noble W, Coelho CB, Ji H. Tinnitus 27. Meikle MB, Henry JA, Griest SE, et al. The retraining therapy: mixing point and total masking tinnitus functional index: development of a new are equally effective. Ear Hear 2012;33(5):588–594 clinical measure for chronic, intrusive tinnitus. Ear 12. Goodey R. Introduction to management of tinni- Hear 2012;33(2):153–176 tus. In: Moller A, Langguth B, DeRidder D, 28. Cronlein T, Geisler P, Hajak G. Introduction to Kleinjung T, eds. Textbook of Tinnitus. New management of tinnitus. In: Moller A, Langguth York, NY: Springer; 2011. Ch.68. p. 524 B, DeRidder D, Kleinjung T, eds. Textbook of 13. Rauschecker JP, Leaver AM, Mu¨hlau M. Tuning Tinnitus. New York, NY: Springer; 2011. out the noise: limbic-auditory interactions in tin- Ch.68.505–510 nitus. Neuron 2010;66(6):819–826 29. Reavis K, Chang J, Zeng F. Patterned sound 14. Henry J, Wilson P. Psychological treatments for therapy for the treatment of tinnitus. Hear J tinnitus. In: Vernon J, ed. Tinnitus Treatment and 2010;63:21–24

Relief. Boston, MA: Allyn & Bacon; 1998:99–102 30. Okamoto H, Stracke H, Stoll W, Pantev C. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 15. Beck J. Cognitive Behavior Therapy: Basics and Listening to tailor-made notched music reduces Beyond. New York, NY: Guilford Press; 2011: tinnitus loudness and tinnitus-related auditory 1–17 cortex activity. Proc Natl Acad Sci U S A 2010; 16. Sweetow R. Widex A/S. Widex Zen Therapy: 107(3):1207–1210 Managing the Effects of Tinnitus. Copenhagen, 31. Jastreboff P, Jastreboff M. Hyperacusis. 2001. Denmark, 2012 Available at http://www.audiologyonline.com/ar- 17. Searchfield G, Magnusson J, Shakes G, Biesinger ticles/hyperacusis-1223. Accessed December 4, E, Kong O. Counseling and psycho-education for 2013 130 SEMINARS IN HEARING/VOLUME 35, NUMBER 2 2014

Appendix A: List of Helpful Web Sites for Audiologist and Patient Reference (All Accessed January 15, 2014)

www.ata.org www.helpguide.org/harvard/mindfulness.htm http://mindfultinnitusrelief.com/ www.tinn.com www.medicine.uiowa.edu/oto/research/tinnitus www.amazon.com www.neuromonics.com www.soundcure.com www.tinnituslab.com www.melmedtronics.com www.soundpillow.com www.bedphones.com www.sleepphones.com www.premiermicronutrient.com http://audacity.sourceforge.net This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.